Failure to Adhere to Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to adhere to a physician-ordered fluid restriction for a resident receiving dialysis, identified as Resident 13. The resident, who was admitted with diagnoses including diabetes and end-stage kidney disease, was ordered to maintain a 1000 ml fluid restriction. However, the facility's electronic system was incorrectly set to a 1500 ml fluid restriction, leading to multiple instances where the resident's fluid intake exceeded the prescribed limit. This discrepancy was confirmed through a review of the resident's clinical records and fluid intake reports, which documented several days where the fluid intake surpassed the 1000 ml restriction. The deficiency was further corroborated by an interview with the Director of Nursing, who acknowledged the failure to comply with the physician's order. The facility's policy on fluid management, which requires verification of physician orders and adherence to specified fluid amounts, was not followed, resulting in the resident receiving more fluids than medically prescribed. This oversight highlights a significant lapse in ensuring the resident's care plan was executed as intended, potentially impacting the resident's health due to the excess fluid intake.
Plan Of Correction
The facility cannot retroactively correct the deficiency noted by the surveyor for resident 13. Resident 13's order has been verified to be summarized in the resident's tasks. The facility recognizes that other residents with orders for fluid restrictions have the potential to be affected, and the Director of Nursing (DON) or designee will audit residents with orders for fluid restrictions to verify the orders are being maintained. The DON or designee will re-educate the dietary and nursing staff on following fluid restrictions as ordered. The DON or designee will randomly audit residents with orders for fluid restrictions weekly for 4 weeks and then monthly for 2 months to verify compliance. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months.